Discharging patients in a timely manner remains an important factor in Stanford Hospital's inability to accommodate all patients who need and want services. In 2013, only 15 percent of patients were discharged by noon. The difficulty in freeing up beds with early discharges feeds into greater access and capacity issues. Last year, the Emergency Department boarded an average of 530 patients per month, the Transfer Center had more than 800 denials due to lack of beds, lack of staff, or bed delays, and in January of this year, the hospital experienced such catastrophic crowding that 18 operative cases had to be canceled.
As part of the larger hospital-wide Patient Flow Value Stream work, a multidisciplinary team of physicians, nurses and administrative leaders is focusing on improving the hospital's ability to discharge patients more efficiently and timely. This team is one of many working across the entire patient experience, from admission to discharge transition, to create a coordinated system with high reliability for quality, service and efficiency that accepts every clinically appropriate patient and does not impose delays in care.
"Stanford currently turns patients away who want or need clinical services and our patients are telling us that their care is not well coordinated," says Marlena Kane, executive director, Value Stream Initiatives. "To support increased volume and growth, and improve our patient, staff and physician experience, we have to get creative about how we provide care more efficiently and within our existing hospital framework."
The Patient Flow Value Stream team has identified a number of strategies for improving the hospital's ability to discharge patients when medically ready. These include increasing the use and consistency of estimated discharge date (EDD), increasing the transparency of the discharge plan for patients and staff, and beginning the discharge planning process upon admission.
"One thing we can work on is developing standard work around discharge so that everyone is clear on what needs to happen to ensure patients can be discharged when their provider deems them ready, and so that discharge planning can begin upon their admission," says Kane. Currently, just 12 percent of physicians regularly document an estimated discharge date in Epic, which Kane says, provides a timely, important opportunity to improve documentation and communication around estimated discharge dates.
The Patient Flow Value Stream team is working closely with the General Medicine care team (including hospitalists, nurses, case managers and social workers) to develop clear standards on how and when to document an estimated discharge date into Epic, as well as how to make it visible to the rest of the care team. "Making it visible," says Kane, "will improve communication within the care team, ensure that patients and families are aware of the discharge date, and ultimately remove barriers associated with patients being discharged, such as organizing a ride home from the hospital or ordering durable medical equipment. The goal is to communicate an estimated discharge date within 36 hours of admission so the discharge planning process can start earlier."
According to team member Neera Ahuja, MD, director of the Hospitalist Program, a number of physicians are hesitant to identify a discharge date because they don't want to be wrong. But giving patients a target date, even if it has to be adjusted, helps patients and their care team plan for discharge, she says. To determine the evidence-based practices for EDD, Ahuja conducted a literature search and found that very little research has been conducted on estimating discharge dates.
As a result, she has begun collecting data on three key issues of patient discharge at Stanford Hospital—How does estimating discharge dates affect length of stay? How accurate is SHC in estimating discharge dates? And lastly, is it more difficult to estimate discharge dates for certain patient populations?
To date, Ahuja has collected data on 120 patients on the General Medicine floors. By mid September, she expects to have enough data to share preliminary results. The Patient Flow Value Stream team is focusing initial efforts on General Medicine because approximately 80 percent of inpatients in this area come through the Emergency Department, and this patient population represents about 40 percent of all discharges.