Stanford Hospital has implemented a conditional discharge order, which allows physicians to place orders in advance of the actual discharge date, with specific criteria to be met prior to discharge. Once placed in Epic, the conditional discharge order sends out a highly visible nurse communication order, prompting them to begin routine discharge activities, in addition to the conditional orders specified by the physician.
Since going into effect, about 10 percent of discharges are now conditional discharges, says Paul Maggio, MD, a medical informatics director who worked on the team that developed the new orders. "Our goal is to have discharge orders placed by 8 a.m. on the date of discharge so that we can start to sequence the rest of the activities to discharge by noon," he says. "Realistically the only way you can do that for many services is to use a conditional discharge the day before."
Better utilizing capacity
Conditional discharge orders are also a crucial step in maximizing capacity, adds James Hereford, chief operating officer. As he points out, Stanford is a relatively small hospital running at 90 percent capacity nearly all the time. When surges occur in the OR schedule or in the ED, as they did during January's influenza outbreak, capacity can become strained, leading to canceled cases, patients stranded in the ED and halts on transfer orders.
"This new discharge order is one piece of a whole effort to use capacity as best we can," says Hereford. "One of our challenges is that our discharge by noon rate is really low at only seven percent. Little to no output means it's hard to have input." To deal with this measure, Hereford has given the inpatient team a target of discharging 40 percent of patients by noon by August of this year.
How it works
There are now two options available in Epic to discharge a patient: discharge and conditional discharge. The conditional discharge option includes all the same information as a normal discharge screen, but it also includes discharge criteria and a comment box to include further instructions to the care team. Physicians can use pull down templates to select standard conditional discharge criteria such as: when tolerating oral diet/oral medication; when able to void after Foley catheter removal/ambulate; when evaluated by attending/chief resident; and when cleared by physical therapy/occupational therapy/speech therapy.
The conditional discharge orders give our physicians flexibility, says Hereford. Physicians can place discharge orders the night before. They don't have to be at the hospital as early in the morning to be able to put those orders in place. "It is also better for nurses," says Maggio. "It gives them extra lead time to complete the several hours of work that need to get done before discharge."
Although the conditional discharge in itself does not make the discharge process quicker, it can start the process earlier, says Maggio. There's a complex choreography that comes into play to manage an effective discharge and transition. Nursing plays a critical role in that process, says Hereford. An evening conditional discharge order can relieve some of the stress of the morning discharge order.
"I think it provides a more effective and clear tool to communicate with the whole team about discharge," says Lisa Shieh, MD, unit-based medical director for B3/C3. In the past, the culture was to put the discharge order in fairly close to the time the patient was going to be ready to leave, she adds. "This gives us an opportunity to place the order earlier and communicate better with the whole health care team that this patient can leave when these conditions are met."
As Carole Nakamura, RN, points out, some physicians do not include any comments on their discharge orders, which causes a lot of questions on the nursing side. The new conditional discharge order is clearer, she says. It reduces the number of times nurses need to page physicians for ambiguous orders or unanswered questions.
"I think it's helpful," she adds. "It's a template order set for the doctor. If they select these things, we see it very clearly."
By Grace Hammerstrom